Original Article
The Effects of Virtual Reality-based Balance Training on Balance of the Elderly
J. Phys. Ther. Sci. 26: 615–617, 2014
Gyeong Hee Cho, PT, MS1), Gak Hwangbo, PhD, PT1)*, Hyung Soo Shin, PhD, PT2) 1) Department
of Physical Therapy, College of Rehabilitation Science, Daegu University: 15 Jillyang, Gyeongsan-si, Kyeongbuk 712-714, Republic of Korea 2) Department of Physical Therapy, Kyungwoon University, Republic of Korea
Abstract. [Purpose] The objective of this study was to determine the effects of virtual reality-based balance training on balance of the elderly. [Methods] The subjects were 32 healthy elderly people aged between 65 and 80, who were divided into a VR (virtual reality) training group (n=17) and a control group (n=15). The VR training group engaged in a 30-minute exercise session using Wii Fit three times a week for eight weeks, while the control group received no intervention. The balance of the two groups was measured before and after the intervention. [Results] According to the Romberg Test conducted to examine the effects of the training on balance, both the area covered by the body’s center of pressure movement, and movement distances per unit area of the body’s center of pressure envelope significantly decreased in the VR training group. Moreover, the two groups showed significant differences in balance. [Conclusion] Virtual reality training is effective at improving the balance of the healthy elderly. Thus, virtual reality training can be proposed as a form of fall prevention exercise for the elderly. Key words: Virtual reality training, Balance, Elderly (This article was submitted Oct. 1, 2013, and was accepted Nov. 21, 2013)
INTRODUCTION About 30% of the elderly aged 65 years or older experience a fall at least once a year, and 15% fall twice or more per year1, 2). A fall can result in serious injuries, such as fracture or dislocation, as well as minor injuries, such as contusion and sprain. Many elderly people who sustain a severe fracture do not recover to their prior functional level and some even die3). In addition, a fall restricts elderly people’s activities of daily living, leading to loss of independence, hospitalization, increased medical costs, and a greater economic burden4). Recent technological advances have led to the introduction of new virtual reality-based exercise methods for performing diverse tasks5). Flynn et al.6) observed that virtual reality provides interest and fun and motivates the user. Clark et al.7) and Yamada et al.8) noted that the reliability of virtual reality-based exercise regimes has been proven. Research on virtual reality is ongoing. Interactive virtual reality is defined as a tool for interaction between a user and his or her computer. Virtual reality makes it possible to perform a much larger range of activities and to create more diverse movements than in actual situations. Via virtual reality, users interact with created scenarios or envi*Corresponding author. Gak Hwangbo (E-mail: hbgak@ daegu.ac.kr) ©2014 The Society of Physical Therapy Science. Published by IPEC Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-ncnd) License .
ronments through diverse sensory channels9). Sensory feedback (auditory, vision, and proprioception) can be provided in virtual environment exercise training programs, and the program can be tailored to each individual by changing the level of exercise according to the individual’s degree of adaptation to the training10). Adamovich et al.11) proposed that the rapid development of virtual reality technology raised the possibility of developing new exercise strategies. Many previous studies have examined the use of virtual reality in treating various conditions, such as stroke12), cerebral palsy13), and traumatic brain injury14). The present study investigated changes in the balance ability of healthy elderly people following virtual-reality balance training for the prevention of falls. SUBJECTS AND METHODS The subjects were 32 healthy elderly people aged between 65 and 80 years who were randomly assigned to either a virtual reality training group (n=17) or a control group (n=15). The virtual reality training group received training three times per week for eight weeks with a Nintendo Wii Fit program, while the control group received no intervention. Those whose score on the Korean mini-mental status exam was lower than 23 and who had been diagnosed with an orthopedic disease, such as fracture, within the previous six months were excluded from this study. Additional exclusion criteria were the presence of any visual or auditory abnormality; the consumption of drugs, such as opiates or alcohol; the consumption of strepto antibiotics affecting balance prior to the examination; and the presence of a progressive disorder or neurological disturbance (e.g., Parkinson’s dis-
616 J. Phys. Ther. Sci. Vol. 26, No. 4, 2014 ease, Alzheimer’s disease, multiple sclerosis, epilepsy, or stroke). All included patients understood the purpose of this study and provided their written informed consent prior to their participation in the study in accordance with the ethical principles of the Declaration of Helsinki. Subjects’ balance with their eye open and closed was measured using the Romberg test on a Bio-rescue (RM INGENERIE, France). For the starting position, the subjects placed their second toe on a diagonal line drawn on the foot plate, put their heels together, and maintained an angle of 30 degrees between the feet. Measurements were taken with the subject’s eyes open for 60 seconds, and with their eyes closed for 60 seconds. The Nintendo Wii Fit device used in the virtual reality training consists of a balance board and a CD. When a subject mounts the balance board, an avatar appears on the screen and imitates the subject’s movements. The equipment not only provide visual and auditory feedback, but also tactile feedback through vibration the Wii remote control. The following balance games were used in this study: ski slalom, table tile, and balance bubble. The subjects took part in each of the programs for 10 minutes. When the subjects performed each program, they had to move their center of gravity without changing the position of their feet on the balance board. The means and standard errors of all variables were calculated using SPSS 20.0 KO (IBM, IL, USA). The independent t-test was carried out to determine statistical variations between the groups. In addition, the paired t-test was conducted to verify changes within each group prior to and after the virtual reality training. Statistical significance was accepted for values of p
The Effects of Virtual Reality-based Balance Training on Balance of the Elderly
J. Phys. Ther. Sci. 26: 615–617, 2014
Gyeong Hee Cho, PT, MS1), Gak Hwangbo, PhD, PT1)*, Hyung Soo Shin, PhD, PT2) 1) Department
of Physical Therapy, College of Rehabilitation Science, Daegu University: 15 Jillyang, Gyeongsan-si, Kyeongbuk 712-714, Republic of Korea 2) Department of Physical Therapy, Kyungwoon University, Republic of Korea
Abstract. [Purpose] The objective of this study was to determine the effects of virtual reality-based balance training on balance of the elderly. [Methods] The subjects were 32 healthy elderly people aged between 65 and 80, who were divided into a VR (virtual reality) training group (n=17) and a control group (n=15). The VR training group engaged in a 30-minute exercise session using Wii Fit three times a week for eight weeks, while the control group received no intervention. The balance of the two groups was measured before and after the intervention. [Results] According to the Romberg Test conducted to examine the effects of the training on balance, both the area covered by the body’s center of pressure movement, and movement distances per unit area of the body’s center of pressure envelope significantly decreased in the VR training group. Moreover, the two groups showed significant differences in balance. [Conclusion] Virtual reality training is effective at improving the balance of the healthy elderly. Thus, virtual reality training can be proposed as a form of fall prevention exercise for the elderly. Key words: Virtual reality training, Balance, Elderly (This article was submitted Oct. 1, 2013, and was accepted Nov. 21, 2013)
INTRODUCTION About 30% of the elderly aged 65 years or older experience a fall at least once a year, and 15% fall twice or more per year1, 2). A fall can result in serious injuries, such as fracture or dislocation, as well as minor injuries, such as contusion and sprain. Many elderly people who sustain a severe fracture do not recover to their prior functional level and some even die3). In addition, a fall restricts elderly people’s activities of daily living, leading to loss of independence, hospitalization, increased medical costs, and a greater economic burden4). Recent technological advances have led to the introduction of new virtual reality-based exercise methods for performing diverse tasks5). Flynn et al.6) observed that virtual reality provides interest and fun and motivates the user. Clark et al.7) and Yamada et al.8) noted that the reliability of virtual reality-based exercise regimes has been proven. Research on virtual reality is ongoing. Interactive virtual reality is defined as a tool for interaction between a user and his or her computer. Virtual reality makes it possible to perform a much larger range of activities and to create more diverse movements than in actual situations. Via virtual reality, users interact with created scenarios or envi*Corresponding author. Gak Hwangbo (E-mail: hbgak@ daegu.ac.kr) ©2014 The Society of Physical Therapy Science. Published by IPEC Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-ncnd) License .
ronments through diverse sensory channels9). Sensory feedback (auditory, vision, and proprioception) can be provided in virtual environment exercise training programs, and the program can be tailored to each individual by changing the level of exercise according to the individual’s degree of adaptation to the training10). Adamovich et al.11) proposed that the rapid development of virtual reality technology raised the possibility of developing new exercise strategies. Many previous studies have examined the use of virtual reality in treating various conditions, such as stroke12), cerebral palsy13), and traumatic brain injury14). The present study investigated changes in the balance ability of healthy elderly people following virtual-reality balance training for the prevention of falls. SUBJECTS AND METHODS The subjects were 32 healthy elderly people aged between 65 and 80 years who were randomly assigned to either a virtual reality training group (n=17) or a control group (n=15). The virtual reality training group received training three times per week for eight weeks with a Nintendo Wii Fit program, while the control group received no intervention. Those whose score on the Korean mini-mental status exam was lower than 23 and who had been diagnosed with an orthopedic disease, such as fracture, within the previous six months were excluded from this study. Additional exclusion criteria were the presence of any visual or auditory abnormality; the consumption of drugs, such as opiates or alcohol; the consumption of strepto antibiotics affecting balance prior to the examination; and the presence of a progressive disorder or neurological disturbance (e.g., Parkinson’s dis-
616 J. Phys. Ther. Sci. Vol. 26, No. 4, 2014 ease, Alzheimer’s disease, multiple sclerosis, epilepsy, or stroke). All included patients understood the purpose of this study and provided their written informed consent prior to their participation in the study in accordance with the ethical principles of the Declaration of Helsinki. Subjects’ balance with their eye open and closed was measured using the Romberg test on a Bio-rescue (RM INGENERIE, France). For the starting position, the subjects placed their second toe on a diagonal line drawn on the foot plate, put their heels together, and maintained an angle of 30 degrees between the feet. Measurements were taken with the subject’s eyes open for 60 seconds, and with their eyes closed for 60 seconds. The Nintendo Wii Fit device used in the virtual reality training consists of a balance board and a CD. When a subject mounts the balance board, an avatar appears on the screen and imitates the subject’s movements. The equipment not only provide visual and auditory feedback, but also tactile feedback through vibration the Wii remote control. The following balance games were used in this study: ski slalom, table tile, and balance bubble. The subjects took part in each of the programs for 10 minutes. When the subjects performed each program, they had to move their center of gravity without changing the position of their feet on the balance board. The means and standard errors of all variables were calculated using SPSS 20.0 KO (IBM, IL, USA). The independent t-test was carried out to determine statistical variations between the groups. In addition, the paired t-test was conducted to verify changes within each group prior to and after the virtual reality training. Statistical significance was accepted for values of p
